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FSI 302a (1/17

NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, New York 12235

LICENSE FEE: $400.00 Office Use Only
County Code- Est. No.
License Expiration: Two years from date of issuance.

Entity No. ___________________
Receipt No. __________________
Verification No. _______________

Read and complete both sides of this application.
Prepare a separate application for each location.
An original signature of owner or corporate officer is
required in Section (7).
NOTE: This license is ONLY for food warehouses where food is held for commercial distribution.
(1) Individual Owner Name, Partnership or Full Name of the Corporation: County:

Trade Name: Business Telephone Number:
( )
Street: City: State: Zip:

E-Mail: Bank Name:

(2) Optional Mailing Address:
Street: City: State: Zip:

(3) Identification Number:
Federal ID Number OR Social Security Number

(4) Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership, LLC, or LLP, list partners/members
(attach list if necessary). If applicant is a non-public corporation, list shareholders (attach list if necessary).
Title Work Address (Street & No., City, State, Zip)
Name (Please Print) Date of Birth
E-Mail address

(4a.) Principal Office Address: ______________________________________________________________________________________________

(4b.) In what state incorporated? ________________________ (4c.) Date of Incorporation _____________________________________________

(4d.) Are you a foreign or out- of-New-York-state individual, partnership, or corporation? (Check One) Yes  No 
(4e.) For foreign or out-of-New-York-state corporations:
Date of filing in New York State? ____________________

(4f.) If out-of-New-York-state, the applicant agrees to accept service of process by first class mail to the designated individual at the said address below
which shall constitute good and proper service of process.

Designated:_____________________________________ Address: _______________________________________________________


officer.sm.gov. partner or share/stockholder. (5) List all food at this location to be covered by this license. maintenance and operation of the establishment is such that products handled therein will not be adulterated. with respect to an offense involving. food safety. sanitary controls. buildings and offices to the Commissioner. If you have questions about the information requested. call (518) 457-7139. in support of this application. licensee. Applicant consents to free entry and will permit free access to the licensed premises. The authority to solicit the information requested above is found in Section 16 of the Agriculture and Markets Law in the sections relating to the specific license you are seeking. This definition shall be construed as including chewing gum.45 of the Penal Law of the State of New York. any false statements made herein are punishable pursuant to Section 210. for all purposes. has been convicted of. NY 12235. pursuant to Article 28 of the Agriculture and Markets Law of the State of New York and. 10B Airline Drive.foodlicense@agriculture. or write to: NYS Department of Agriculture and Markets. makes the above statements and agrees to comply with the requirements of Article 28. director. ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ _________________________________________________________________________________________________________ (6) Workers Compensation Law requires that businesses seeking state issued permits demonstrate that they have appropriate Workers Compensation Insurance (WCI). PARTNER OR CORPORATE OFFICER TITLE DATE AUTHORIZATION AND PURPOSE Disclosure of your federal social security and federal employer identification numbers is mandatory and is authorized by Section 5 of the New York State Tax Law. drink. records and practices exist to maintain the establishment in a clean and sanitary condition and that the cleaning. confectionery or condiment. NOTE: Your application for a license is subject to denial and/or revocation. it is determined that the applicant. as the equivalent of an Affidavit. and shall also include all substances or ingredients to be added to food for any purpose. This information is collected to enable the Department to evaluate your application. e-mail agr. Attn: Food Safety License Unit. mixed or compound. sale and use of articles subject to the Commissioner’s jurisdiction.ny. after a hearing. ORIGINAL SIGNATURE OF OWNER. Indicate your WCI status: Insured with __________________________________________________ Self Insured Exempt from WCI Name of Insurance Provider (7) The undersigned applies for a license to operate a food warehouse at this location only. This information is collected to enable the Department of Taxation and Finance to identify individuals. . or has pled guilty to a felony in any court of the United States or any State or territory thereof. Applicant understands the statements made in this application will be accepted. to determine if it should be issued and to assist in the enforcement and administration of the Agriculture and Markets Law. The issuance of a license is based upon continued compliance with all requirements associated with operating a food warehouse. used or intended for use by men or animals. businesses and others who have been delinquent in filing tax returns or may have understated their tax liability and to generally identify persons affected by the Tax Law administered by the Commissioner of Taxation and Finance administering the Tax Law and for any other purpose authorized by the Tax Law. whether simple. if. The terms “food” and “food product” shall include all articles of food. equipment. the Commissioner’s agents and inspectors in pursuance of the Commissioner’s duty to supervise and regulate storage. In addition to being a basis for denial or revocation of license. Albany. food adulteration or food misbranding. The applicant represents that adequate physical facilities.

agriculture. for the amount indicated above only. This is permission for a single transaction only. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. I certify that I am an authorized user of this credit card.gov . 12235 │ (518) 457-7139 │ www. N. One Time Credit Card Payment Authorization Form Sign and complete this form to authorize the NYS Department of Agriculture and Markets to make a one time debit to your credit card listed below. authorize the NYS Department of Agriculture and Markets to charge my credit card account indicated below for $400. Division of Food Safety & Inspection │ 10B Airline Dr. Please mail to the below address.:_________________ CVV2 (3 digit number on back of Visa/MC. 4 digits on front of AMEX)_______ SIGNATURE DATE I authorize the NYS Department of Agriculture and Markets to charge the credit card indicated in this authorization form according to the terms outlined above.Y.00.. This payment authorization is for a Food Warehouse License.ny. Please complete the information below: I _________________________________.: __________________ Expiration Date _______________ License No. and does not provide authorization for any additional unrelated debits or credits to your account. This payment is for a: FOOD WAREHOUSE LICENSE Billing Address ________________________________ Phone# ________________________ City _________________________________________ State _______ Zip ________ Email ____________________________________________________________________________ Account Type: Visa MasterCard AMEX Discover Cardholder Name _____________________________________________ FOR OFFICE USE ONLY Account Number _____________________________________________ Estab No. Albany. and is valid for one time use only.